The following standards for benefits are prescribed for the
categories of coverage noted in the following subsections. An accident and
health insurance policy or certificate subject to this rule shall not be
delivered or issued for delivery unless it meets the required standards for the
specified categories. This section shall not preclude the issuance of any
policy or contract combining two or more categories set forth in Subsection
31A-22-605(5).
Benefits for coverages listed in this section shall include
coverage of inborn metabolic errors as required by Section
31A-22-623
and Rule R590-194, and benefits for diabetes as required by Section
31A-22-626
and Rule R590- 200, if applicable.
(1)
Basic Hospital Expense Coverage.
Basic hospital expense coverage is a policy of accident and
health insurance that provides coverage for a period of not less than 31 days
during a continuous hospital confinement for each person insured under the
policy, for expense incurred for necessary treatment and services rendered as a
result of accident or sickness, and shall include at least the
following:
(a) daily hospital room and
board in an amount not less than:
(i) 80% of
the charges for semiprivate room accommodations; or
(ii) $100 per day;
(b) miscellaneous hospital services for
expenses incurred for the charges made by the hospital for services and
supplies that are customarily rendered by the hospital and provided for use
only during any one period of confinement in an amount not less than either:
(i) 80% of the charges incurred up to at
least $3000; or
(ii) ten times the
daily hospital room and board benefits; and
(c) hospital outpatient services consisting
of:
(i) hospital services on the day surgery
is performed;
(ii) hospital
services rendered within 72 hours after injury, in an amount not less than $250
per accident; and
(iii) x-ray and
laboratory tests to the extent that benefits for the services would have been
provided if rendered to an in-patient of the hospital to an extent not less
than $200;
(d) benefits
provided under Subsections (a) and (b) may be provided subject to a combined
deductible amount not in excess of $200.
(2) Basic Medical-Surgical Expense Coverage.
Basic medical-surgical expense coverage is a policy of
accident and health insurance that provides coverage for each person insured
under the policy for the expenses incurred for the necessary services rendered
by a physician for treatment of an injury or sickness for and shall include at
least the following:
(a) surgical
services:
(i) in amounts not less than those
provided on a current procedure terminology based relative value fee schedule,
up to at least $1000 for one procedure; or
(ii) 80% of the reasonable charges.
(b) anesthesia services,
consisting of administration of necessary general anesthesia and related
procedures in connection with covered surgical service rendered by a physician
other than the physician, or the physician assistant, performing the surgical
services:
(i) in an amount not less than 80%
of the reasonable charges; or
(ii)
15% of the surgical service benefit; and
(c) in-hospital medical services, consisting
of physician services rendered to a person who is a bed patient in a hospital
for treatment of sickness or injury other than that for which surgical care is
required, in an amount not less than:
(i) 80%
of the reasonable charges; or
(ii)
$100 per day.
(3) Basic Hospital/Medical-Surgical Expense
Coverage.
Basic hospital/medical-surgical expense coverage is a policy
of accident and health which combines coverage and must meet the requirements
of both Subsections R590-126-7(1) and (2).
(4) Hospital Confinement Indemnity Coverage.
(a) Hospital confinement indemnity coverage
is a policy of accident and health insurance that provides daily benefits for
hospital confinement on an indemnity basis.
(b) Coverage includes an indemnity amount of
not less than $50 per day and not less than 31 days during each period of
confinement for each person insured under the policy.
(c) Benefits shall be paid regardless of
other coverage.
(5)
Income Replacement Coverage.
Income replacement coverage is a policy of accident and
health insurance that provides for periodic payments, weekly or monthly, for a
specified period during the continuance of disability resulting from either
sickness or injury or a combination of both that:
(a) contains an elimination period no greater
than:
(i) 90-days in the case of a coverage
providing a benefit of one year or less;
(ii) 180 days in the case of coverage
providing a benefit of more than one year but not greater than two years;
or
(iii) 365 days in all other
cases during the continuance of disability resulting from sickness or
injury;
(b) has a
maximum period of time for which it is payable during disability of at least
six months except in the case of a policy covering disability arising out of
pregnancy, childbirth or miscarriage in which case the period for the
disability may be one month. No reduction in benefits shall be put into effect
because of an increase in Social Security or similar benefits during a benefit
period;
(c) where a policy provides
total disability benefits and partial disability benefits, only one elimination
period may be required;
(d) a
policy which provides for residual disability benefits may require a
qualification period, during which the insured shall be continuously totally
disabled before residual disability benefits are payable. The qualification
period for residual benefits may be longer than the elimination period for
total disability;
(e) the
provisions of this subsection do not apply to policies providing business
buyout coverage.
(6)
Accident Only Coverage.
Accident only coverage is a policy of accident and health
insurance that provides coverage, singly or in combination, for death,
dismemberment, disability or hospital and medical care caused by accident.
Accidental death and double dismemberment amounts under the policy shall be at
least $1,000 and a single dismemberment amount shall be at least $500.
(7) Specified Accident Coverage.
Specified accident coverage is a policy of accident and
health insurance that provides coverage for a specifically identified kind of
accident, or accidents, for each person insured under the policy for accidental
death or accidental death and dismemberment, combined with a benefit amount not
less than $1,000 for accidental death, $1,000 for double dismemberment and $500
for single dismemberment.
(8) Specified Disease Coverage.
Specified disease coverage is a policy of accident and health
insurance that provides coverage for the diagnosis and treatment of a
specifically named disease or diseases, and includes critical illness
coverages. Any such policy shall meet these general provisions. The policy
shall also meet the standards set forth in the applicable Subsections
R590-126-7(8)(b), (c) or (d).
(a)
General Provisions.
(i) Policy designation.
Policies covering a single specified disease or combination of specified
diseases may not be sold or offered for sale other than as specified disease
coverage under this Subsection (8).
(ii) Medical diagnosis. Any policy issued
pursuant to this section which conditions payment upon pathological diagnosis
of a covered disease, shall also provide that if a pathological diagnosis is
medically inappropriate, a clinical diagnosis will be accepted
instead.
(iii) Related conditions.
Notwithstanding any other provision of this rule, specified disease policies
shall provide benefits to any covered person, not only for the specified
disease, but also for any other condition or disease directly caused or
aggravated by the specified disease or the treatment of the specified
disease.
(iv) Renewability.
Specified disease coverage shall be at least guaranteed renewable.
(v) Probationary period. No policy issued
pursuant to this section may contain a probationary period greater than 30
days.
(vi) Medicaid disclaimer. Any
application for specified disease coverage shall contain a statement above the
signature of the applicant that no person to be covered for specified disease
is also covered by any Title XIX program, designated as Medicaid or any similar
name. Such statement may be combined with any other statement for which the
insurer may require the applicant's signature.
(vii) Medical Care. Payments may be
conditioned upon an insured person's receiving medically necessary care, given
in a medically appropriate location, under a medically accepted course of
diagnosis or treatment.
(viii)
Other insurance. Benefits for specified disease coverage shall be paid
regardless of other coverage.
(ix)
Retroactive application of coverage. After the effective date of the coverage,
or the conclusion of an applicable probationary period, if any, benefits shall
begin with the first day of care or confinement, if such care or confinement is
for a covered disease, even though the diagnosis is made at some later
date.
(x) Hospice. Hospice care is
an optional benefit, but if offered it shall meet the following minimum
standards:
(A) eligibility for payment of
benefits when the attending physician of the insured provides a written
statement that the insured person has a life expectance of six months or
less;
(B) fixed-sum payment of at
least $50 per day; and
(C) lifetime
maximum benefit of at least $10,000.
(b) Expense Incurred Benefits. The following
benefit standards apply to specified disease coverage on an expense-incurred
basis.
(i) Policy limits. A deductible amount
not to exceed $250, an aggregate benefit limit of not less than $25,000 and a
benefit period of not fewer than three years.
(ii) Copayment. Covered services provided on
an outpatient basis may be subject to a copayment, which may not exceed
20%.
(iii) Covered Services.
Covered services shall include the following:
(A) hospital room and board and any other
hospital-furnished medical services or supplies;
(B) treatment by, or under the direction of,
a legally qualified physician or surgeon;
(C) private duty nursing services of a
registered nurse, or licensed practical nurse;
(D) x-ray, radium, chemotherapy and other
therapy procedures used in diagnosis and treatment;
(E) blood transfusions, and the
administration thereof, including expense incurred for blood donors;
(F) drugs and medicines prescribed by a
physician;
(G) professional
ambulance for local service to or from a local hospital;
(H) the rental of any respiratory or other
mechanical apparatuses;
(I) braces,
crutches and wheelchairs as are deemed necessary by the attending physician for
the treatment of the disease;
(J)
emergency transportation if, in the opinion of the attending physician, it is
necessary to transport the insured to another locality for treatment of the
disease;
(K) home health care with
a written prescribed plan of care;
(L) physical, speech, hearing and
occupational therapy;
(M) special
equipment including hospital bed, toilette, pulleys, wheelchairs, aspirator,
chux, oxygen, surgical dressings, rubber shields, colostomy and eleostomy
appliances;
(N) prosthetic devices
including wigs and artificial breasts;
(O) nursing home care for non-custodial
services; and
(P) reconstructive
surgery when deemed necessary by the attending physician.
(c) Per Diem Benefits. The
following benefit standards apply to specified disease coverage on a per diem
basis.
(i) Covered services shall include the
following:
(A) hospital confinement benefit
with a fixed-sum payment of at least $200 for each day of hospital confinement
for at least 365 days, with no deductible amount permitted;
(B) outpatient benefit with a fixed-sum
payment equal to one half the hospital inpatient benefits for each day of
hospital or non-hospital outpatient surgery, radiation therapy and
chemotherapy, for at least 365 days of treatment; and
(C) blood and plasma benefit with a fixed-sum
benefit of at least $50 per day for blood and plasma, which includes their
administration whether received as an inpatient or outpatient for at least 365
days of treatment.
(ii)
Benefits tied to confinement in a skilled nursing home or home health care are
optional. If a policy offers these benefits, they must equal the following:
(A) fixed-sum payment equal to one-half the
hospital inpatient benefit for each day of skilled nursing home confinement for
at least 180 days; and
(B)
fixed-sum payment equal to one-fourth the hospital inpatient benefit for each
day of home health care for at least 180 days.
(C) Any restriction or limitation applied to
the benefits may not be more restrictive than those under Medicare.
(d) Lump Sum Benefits.
The following benefit standards apply to specified disease coverage on a lump
sum basis.
(i) Benefits shall be payable as a
fixed, one-time payment, made within 30 days of submission to the insurer, of
proof of diagnosis of the specified disease. Dollar benefits shall be offered
for sale only in even increments of $1,000.
(ii) Where coverage is advertised or
otherwise represented to offer generic coverage of a disease or diseases, e.g.,
"cancer insurance," "heart disease insurance," the same dollar amounts shall be
payable regardless of the particular subtype of the disease, e.g., lung or bone
cancer, with one exception. In the case of clearly identifiable subtypes with
significantly lower treatment costs, e.g., skin cancer, lesser amounts may be
payable so long as the policy clearly differentiates that subtype and its
benefits.
(9)
Limited Benefit Health Coverage.
Limited benefit health coverage is a policy of accident and
health insurance, other than a policy covering only a specified disease or
diseases, that provides benefits that are less than the standards for benefits
required under this Section. These policies or contracts may be delivered or
issued for delivery with the outline of coverage required by Section
R590-126-8.
